<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket>
<wicket:panel>
    <h1 class="pageTitle">
        <wicket:message key="titel"/>
    </h1>
    <div class="row-fluid">
        <div class="span6" wicket:id="labformulier">

        </div>
        <div class="span6">
            <fieldset>
                <form wicket:id="form" class="form-horizontal">
                    <div class="control-group">
                        <label class="control-label">
                            <wicket:message key="barcode"/>
                        </label>

                        <div class="controls">
                            <input class="input" type="text" wicket:id="barcode">
                        </div>
                    </div>
                    <div class="control-group" wicket:id="monsterstatusContainer">
                        <label class="control-label">Status monster</label>

                        <div class="controls">
                            <strong wicket:id="uitstrijkje.uitstrijkjeStatus"/>
                        </div>
                    </div>
                    <hr/>
                    <div class="control-group value">
                        <label class="control-label">Cli&euml;nt</label>

                        <div class="controls">
                            <strong wicket:id="clientNaam"/>
                        </div>
                    </div>
                    <div class="control-group value">
                        <label class="control-label">Geboortedatum</label>

                        <div class="controls">
                            <strong wicket:id="uitstrijkje.uitnodiging.screeningRonde.dossier.client.persoon.geboortedatum"/>
                        </div>
                    </div>
                    <div class="control-group value">
                        <label class="control-label">BSN</label>

                        <div class="controls">
                            <strong wicket:id="uitstrijkje.uitnodiging.screeningRonde.dossier.client.persoon.bsn"/>
                        </div>
                    </div>
                    <div class="control-group value">
                        <label class="control-label">Screeningsorganisatie</label>

                        <div class="controls">
                            <strong wicket:id="uitstrijkje.uitnodiging.screeningRonde.dossier.client.persoon.gbaAdres.gbaGemeente.screeningOrganisatie.naam"/>
                        </div>
                    </div>

                    <div wicket:id="datumUitstrijkjeContainer">
                        <hr/>

                        <div class="control-group">
                            <label class="control-label">Datum uitstrijkje</label>

                            <div class="controls">
                                <div class="input-append">
                                    <input type="text" class="datum" wicket:id="datumUitstrijkje"/>
                                    <a href="javascript:void(0);" class="btn" onclick="$(this).prev().datepicker('show');"><i
                                            class="icon-calendar"></i></a>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div wicket:id="medischeGegevensContainer">
                        <hr style="margin: 20px 0 0"/>
                        <div class="control-group">
                            <label class="control-label">Klachten</label>

                            <div class="controls">
                                <label class="checkbox" style="margin-bottom: 0px">
                                    <input type="checkbox" wicket:id="klachtenGeen">geen
                                </label>
                                <label class="checkbox" style="margin-bottom: 0px">
                                    <input type="checkbox" wicket:id="klachtenContactbloedingen">contactbloedingen
                                </label>
                                <label class="checkbox" style="margin-bottom: 0px">
                                    <input type="checkbox" wicket:id="klachtenKlachtenVanAbnormaleFluorZonderDuidelijkeOorzaak">klachten van abnormale fluor zonder duidelijke
                                    oorzaak
                                </label>
                                <label class="checkbox" style="margin-bottom: 0px">
                                    <input type="checkbox" wicket:id="klachtenIntermenstrueelBloedverlies">intermenstrueel bloedverlies
                                </label>
                                <label class="checkbox" style="margin-bottom: 0px">
                                    <input type="checkbox" wicket:id="klachtenPostmenopauzaalBloedverlies">postmenopauzaal bloedverlies
                                </label>
                                <div class="row-fluid">
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="klachtenAndersNamelijk">anders, namelijk
                                        </label>
                                    </div>
                                    <div class="span8" style="padding-right: 10px">
                                        <textarea style="width: 100%;" rows="1" wicket:id="klachtenAndersNamelijkTekst"/>
                                    </div>
                                </div>
                            </div>
                        </div>
                        <hr style="margin: 5px 0"/>
                        <div class="control-group">
                            <label class="control-label">Menstruatie</label>

                            <div class="controls">
                                <div class="row-fluid">
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="menstruatieNormaal">normaal
                                        </label>
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="menstruatieGeenMenstruatie">geen menstruatie
                                        </label>
                                    </div>
                                    <div class="span8">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="menstruatieMenopauze">menopauze
                                        </label>
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="menstruatiePostmenopauze">postmenopauze
                                        </label>
                                    </div>
                                </div>
                            </div>
                        </div>
                        <hr style="margin: 5px 0"/>
                        <div class="control-group">
                            <label class="control-label">Datum laatste menstruatie</label>

                            <div class="controls">
                                <div class="input-append">
                                    <input type="text" class="datum" wicket:id="datumLaatsteMenstruatie"/>
                                    <a href="javascript:void(0);" class="btn" onclick="$(this).prev().datepicker('show');"><i
                                            class="icon-calendar"></i></a>
                                </div>
                            </div>
                        </div>
                        <hr style="margin: 5px 0"/>
                        <div class="control-group">
                            <label class="control-label">Anticonceptie</label>

                            <div class="controls">
                                <div class="row-fluid">
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="anticonceptieGeen">geen
                                        </label>
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="anticonceptiePil">pil
                                        </label>
                                    </div>
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="anticonceptieIudKoper">IUD koper
                                        </label>
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="anticonceptieIudMirena">IUD mirena
                                        </label>
                                    </div>
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="anticonceptieAnders">anders
                                        </label>
                                    </div>
                                </div>
                            </div>
                        </div>
                        <hr style="margin: 5px 0"/>
                        <div class="control-group">
                            <label class="control-label">Gebruik hormonen</label>

                            <div class="controls">
                                <div class="row-fluid">
                                    <div class="span8">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="gebruikHormonenJaVanwegeOvergangsklachten">ja, vanwege overgangsklachten
                                        </label>
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="gebruikHormonenJaVanwegeBorstkanker">ja, vanwege borstkanker
                                        </label>
                                    </div>
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="gebruikHormonenGeen">geen
                                        </label>
                                    </div>
                                </div>
                                <div class="row-fluid">
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="gebruikHormonenJaVanwege">ja, vanwege
                                        </label>
                                    </div>
                                    <div class="span8" style="padding-right: 10px">
                                        <textarea style="width: 100%; margin-right: 10px" rows="1" wicket:id="gebruikHormonenJaVanwegeTekst"/>
                                    </div>
                                </div>
                            </div>
                        </div>
                        <hr style="margin: 5px 0"/>
                        <div class="control-group">
                            <label class="control-label">Aspect Cervix</label>

                            <div class="controls">
                                <div class="row-fluid">
                                    <div class="span4">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="aspectCervixNormaal">normaal
                                        </label>
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="aspectCervixNietGezien">niet gezien
                                        </label>
                                    </div>
                                    <div class="span8" style="padding-right: 10px">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="aspectCervixAbnormaalOfVerdachtePortio">abnormaal of verdachte portio. <i><b>Belangrijk!</b> Licht
                                            toe.</i>
                                        </label>
                                        <textarea style="width: 100%; margin-right: 10px" wicket:id="aspectCervixAbnormaalOfVerdachtePortioTekst"/>
                                    </div>
                                </div>
                            </div>
                        </div>
                        <hr style="margin: 5px 0"/>
                        <div class="control-group">
                            <label class="control-label">Opmerkingen</label>
                            <div class="controls">
                                <div class="row-fluid">
                                    <div class="span12" style="padding-right: 10px">
                                        <label class="checkbox" style="margin-bottom: 0px">
                                            <input type="checkbox" wicket:id="opmerkingen">
                                            <textarea style="width: 100%; margin-right: 10px" wicket:id="opmerkingenTekst"/>
                                        </label>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>

                    <hr/>

                    <div wicket:id="huisartsLocatieContainer"/>

                    <hr/>

                    <div class="control-group value">
                        <label class="control-label">Scandatum</label>

                        <div class="controls">
                            <strong wicket:id="scanDatum"/>
                        </div>
                    </div>
                    <div class="control-group" wicket:id="labformulierStatusContainer">

                        <label class="control-label">Status formulier</label>

                        <div class="controls">
                            <select wicket:id="status"/>
                        </div>
                    </div>

                    <div class="control-group" wicket:id="labformulierSignaleringenContainer">
                        <label class="control-label">Signalering</label>
                        <div class="controls">
                            <div class="checkbox" wicket:id="signaleringen"></div>
                            <label class="control-label">Overige, namelijk:</label>
                            <div class="controls">
                                <input wicket:id="overigeLabformulierSignalering" class="input-large" type="text">
                            </div>
                        </div>
                    </div>

                </form>

                <hr/>
                <div class="row-fluid text-center">
                    <button type="button" class="btn btn-secondary pull-left" wicket:id="vorige">&#10094; Vorige</button>
                    <span style="line-height: 30px; vertical-align: middle"><span wicket:id="nummer"/>/<span wicket:id="van"/></span>
                    <button type="button" class="btn btn-secondary pull-right " wicket:id="volgende">Volgende &#10095;</button>
                </div>
            </fieldset>
        </div>
    </div>
</wicket:panel>
</html>
